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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 10/12/2022
Date Signed: 10/12/2022 06:28:14 PM


Document Has Been Signed on 10/12/2022 06:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:BROOKDALE KETTLEMAN LANEFACILITY NUMBER:
397005466
ADMINISTRATOR:MARY MARGARET CHAPPELLFACILITY TYPE:
740
ADDRESS:2150 W KETTLEMAN LNTELEPHONE:
(209) 333-8033
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:56CENSUS: 39DATE:
10/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Mary Margaret Chappell, AdministratorTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensed Program Analyst (LPA) R. Campbell conducted a case management visit to this facility on 10/12/22 at approximately 4:00 pm to follow up on an incident report submitted from the facility on 07/15/22. LPA met with Mary Margaret Chappell On 07/09/22, R1 had an unwitnessed fall in the activities room. When staff arrived, he was found laying on the floor. R1 had a small laceration to the right side back of his head. Before calling 911, staff called R1’s responsible party who notified staff he would drive R1 to the hospital. The responsible party arrived a few minutes later to transport R1 to the local hospital.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview with Executive Director. Appeal rights and a copy of report given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2022 06:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: BROOKDALE KETTLEMAN LANE
FACILITY NUMBER: 397005466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2022
Section Cited

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87465(g)Incidental Medical and Dental. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health ...

This requirement is not met as evidenced by:
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Based on observation, interview and record review, the licensee did not call 911 as required by requlations.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
LIC809 (FAS) - (06/04)
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